Prescription drug monitoring programs reduce opioid prescriptions and overdose for adolescents and young adults
Opioid use during adolescence and young adulthood is associated with adverse outcomes. Prescription drug monitoring programs are one policy-level intervention and consist of electronic databases that require routine, scheduled, reporting by pharmacies of prescriptions. Reports include the date medications were dispensed and information on the patient, prescriber, pharmacy, medicine, and dose. This study examined whether implementation of prescription drug monitoring programs that mandated prescriber review led to reduced opioid prescriptions and drug overdose in youth and young adults.
Opioid use, including non-medical prescription drug use, during adolescence and young adulthood can have serious adverse consequences such as the development of a substance use disorder. Rates of drug overdoses among adolescents have also been on the rise. In 2021, there was a 20% increase in overdose deaths compared to 2020, which was nearly double the increased rate of change seen in the overall population. Treatment and recovery services provide help to those currently struggling with opioid use, but policy-level interventions and prevention strategies are also crucial.
Prescription drug monitoring programs are state-level databases that track information on controlled substance prescriptions dispensed by pharmacies to individual patients. Medical providers use the system to identify recently dispensed medications, thereby preventing patients from obtaining opioids and other potentially harmful substances (e.g., benzodiazepines) from multiple providers.
Currently 49 states in the US have implemented such programs. By 2019, 39 states with these programs also mandated that providers review the database prior to prescribing an opioid. Prescription drug monitoring programs may help reduce high-risk opioid prescriptions and minimize the risk of opioid misuse and addiction. However, relatively unexplored is if the rate of opioid prescriptions and related overdoses among adolescents and young adults change in states after they implement such programs. This study examines one commercial insurance claims database containing over 9.3 million young people (aged 13-25) to see if rates of opioid prescriptions and opioid-involved overdoses among adolescents and young adults change after a state implements a prescription drug monitoring program that mandates provider review.
HOW WAS THIS STUDY CONDUCTED?
This study used commercial insurance claims data from over 9.3 million adolescents (aged 13-18) and young adults (aged 19-25) between 2008 and 2019. The number of adolescents and young adults that received an opioid prescription were counted for each month and then summed to give the annual rate of opioid prescriptions. The rate of overdoses among the two groups were derived from the number of adolescents and young adults that had received medical care accompanied by an insurance claim for an opioid-involved overdose (this may result in the underreporting of overdoses). Furthermore, the medical charting and insurance claim data does not distinguish between types of opioids, thus it is unknown whether the opioid overdoses involved fentanyl or fentanyl analogs in this study.
The date when states implemented the prescription drug monitoring program was garnered from the Prescription Drug Monitoring Program Training and Technical Assistance Center. The analysis examined the rates of prescriptions and overdoses in states before and after a state implemented the program, which then enables the study to chart the trends in prescriptions and overdoses among these two populations in the years before and after program implementation. There were additional analyses that measured immediate change in prescriptions and overdoses pre- and post-implementation by restricting analyses to the end of the pre-implementation period to the end of the first month after implementation. The analyses controlled for important state-level policies such as pain clinic legislation and opioid prescribing guidelines outside of the drug monitoring program. However, the analyses did not account for other important state-level policies such as naloxone access laws.
Among the 9.3 million adolescents and young adults in the insurance claims dataset, 1.4 million (15%) had at least one opioid prescription and 6,262 (0.1%) experienced an opioid-involved overdose between 2008 and 2019. Out of the 4.2 million adolescents assessed, 524,445 (12.5 per 100) received an opioid prescription and 1,361 (32.4 per 100,000) experienced an opioid-involved overdose. Among the 6.1 million young adults analyzed, 949,326 (15.4 per 100) received an opioid prescription and 4,941 (80.4 per 100,000) experienced an overdose. Females were prescribed opioids at a higher rate compared to males (16.5 vs. 13.6 per 100), but males experienced overdoses at a higher rate (75 vs. 59 per 100,000). Those living in the South were prescribed opioids at a higher rate compared to the Northeast, Midwest, and West (16 vs. 14, 14, and 15 per 100). Yet those living in the North had the highest rate of overdose compared to those living in the Midwest, South, and West (85 vs. 66, 58, and 63 per 100,000).
WHAT DID THIS STUDY FIND?
Rates of opioid prescriptions decreased more in states with the program.
The rate of opioid prescriptions was found to be on the decline both before and after state implementation of the program. However, states that enacted the program had a larger drop in prescriptions compared to states that did not. Among adolescents, the program was linked to a 4% reduction in opioid prescriptions. For young adults, the program was associated with an 8% reduction in prescriptions. Additionally, there were drops in the rate of prescriptions in the first month immediatelyfollowing implementation of the program among adolescents and young adults—10% and 14% reductions, respectively.
Figure 2. Changes in annual % of dispensed opioid prescriptions after implementation of prescription drug monitoring programs (PDMPs).
Rates of opioid-involved overdoses decreased in states with the program.
Opioid-involved overdoses were increasing among adolescents and young adults before the program was implemented. However, there were reductions in the rates of overdose among both groups in states that enacted the program compared to those that did not. For example, in young adults, an increasing overdose trend before the programs were implemented flattened out after implemented.The study found that the program was associated with 16% reductions in overdoses among adolescents and young adults. Although the program was related to fewer overdoses, there was not an immediate decrease in the rates of overdose among adolescents or young adults following program enactment.
Figure 3. Changes in annual % of opioid-related overdoses after implementation of prescription drug monitoring programs (PDMPs).
Heroin overdoses also decreased in states with the program.
Heroin overdoses were uncommon among adolescents compared to young adults (4 vs. 36 per 100,000). States that implemented the program saw a 17% reduction in heroin-involved overdoses in adolescents and young adults combined.
WHAT ARE THE IMPLICATIONS OF THE STUDY FINDINGS?
This secondary data analysis found states that implemented a prescription drug monitoring program with mandated review had lower rates of opioid prescriptions and opioid-involved overdoses among adolescents and young adults compared to states that did not have the program and before program execution.
Deaths due to drug overdose are steadily increasing among adolescents and young adults in the US. Intervention and prevention strategies vary widely and can include harm-reduction education, opioid reversal (e.g., naloxone) and opioid-use disorder medications (e.g., buprenorphine, methadone), mental health services, substance use treatment, and recovery support services, which may all individually and jointly help reduce opioid-involved harm and overdose.
This study focused on one policy-level prevention strategy and found that there were lower rates of both opioid prescriptions and opioid-involved overdoses among adolescents and young adults in states after they implemented prescription drug monitoring programs with mandated review. Although we cannot say that these programs caused the lower rates in prescriptions or overdoses, they probably helped. That said, these analyses did not control for many policies intended to curb the overdose crisis such as naloxone laws, expanded access to buprenorphine, or syringe services. Furthermore, the benefits of prescription monitoring may take time. In another study, computer modeling suggests the largest public health benefits of reducing opioid prescriptions may not be evident until the second decade of reductions. So, more research is needed to explore how these prescription monitoring programs change prescribing behavior among providers and the downstream impact on adolescents and young adults, especially since only about 20-30% of adolescents and young adults using prescription opioids obtain them from their physician.
Results from this study suggest that prescription monitoring programs may help reduce opioid prescriptions and opioid-involved overdoses. Consequently, policies to monitor and reduce opioid prescriptions should be part of a larger, multi-level national public health strategy that includes expanded access to treatment, harm reduction, and recovery support services, which may have a more immediate impact on reducing opioid-involved harms.
Multi-level strategies are important for many reasons. One reason relevant to this study is that reducing opioid prescriptions may lead to harm for some individuals. Individuals may be adversely affected if their opioid prescription is prematurely or suddenly discontinued without linkage to treatment or compensatory interventions. For example, among adults, there is evidence that reducing access to legal opioids (i.e., prescriptions) leads to increases in illicit opioid use (e.g., heroin). In this study, heroin-involved overdoses did not increase. Youth may not be as physiologically dependent on prescription opioids, on average, so the risks of reducing or eliminating their prescriptions may not be as substantial as for older individuals with longer opioid prescription histories. More research is needed, however, to examine how youth and young adults with opioid-prescription histories respond to reduced opioid prescriptions.
Only one commercial claims database representing 10% of all insured individuals in the US was used for these analyses. So, these results may not generalize to adolescents and young adults on other insurance plans, without insurance, or outside the US.
The analyses were not able to incorporate variables that have been previously linked to substance use and related outcomes such as race, ethnicity, sexual orientation, income, or education.
Opioid-involved overdose was determined by the presence of the ICD-10 diagnosis of opioid poisoning in a medical service claim, which likely underestimates the number of opioid-involved overdoses. Additionally, the ICD-10 opioid-involved overdose diagnosis only indicates either heroin-related overdose orotheropioid-involved overdose. So, the rate of overdoses attributable to fentanyl or fentanyl analogs is unknown.
The data assess the relationship between a state-level policy and annual prescription and overdose rates among individuals. Thus, the study cannot determine if the program caused the rates of prescriptions and overdose to decline among individuals.
BOTTOM LINE
This study analyzed insurance claims among 9.3 million adolescents (aged 13-18) and young adults (aged 19-25) to assess if rates of opioid prescriptions and opioid-involved overdoses changed once statesimplemented a prescription drug monitoring program with mandated review. The study found that prescription rates declined by 4% and 8% among adolescents and young adults, respectively, after program implementation compared to rates prior to program enactment. The study also found that the program was linked to a decline in rates of opioid-involved overdoses by 16% among both adolescents and young adults. Although the study cannot determine if prescription drug monitoring programs caused these declines, they probably helped reduce risky opioid prescriptions and subsequentopioid-involved overdoses. More research is needed to determine how these programs are connected with prescribing practices and overdoses over time. This is especially true since mortality ratesattributed to opioids are on the rise since 2019, the last year captured by the current study data.
For individuals and families seeking recovery: If you or a loved one is going to receive medical care that is typically accompanied by an opioid prescription, it is advised to follow medical recommendations from your provider regarding the medication. Providers in most states are now required to review drug prescription databases to help prevent risky prescribing of medications. The added layers of review surrounding opioid prescriptions have been linked to lower rates of opioid prescriptions and overdose rates among adolescents and young adults aged 13-25.
For treatment professionals and treatment systems: In this secondary analysis of over 9.3 million adolescents and young adults, states saw significant reductions in rates of opioid prescriptions and opioid-involved overdose after they implemented prescription drug monitoring programs with mandated review. The study shows that policy-level prevention strategies like prescription drug monitoring programs may help temper risky opioid prescribing and opioid-involved overdose. However, it is also important to consider empirically supported tapering protocols and linkages to substance use disorder treatment and recovery services for adolescents and young adults.
For scientists:The current study demonstrated a connection between a prescription drug monitoring program and reductions in both the rates of opioid prescriptions and opioid-involved overdoses among adolescents and young adults. Whereas specific causal attributions to the policy are unclear, it is likely to have exerted direct and indirect positive effects. Although the study analyzed a very large sample of young people, future research is needed to confirm if these results apply to those that are not members of this insurer or do not have insurance. Future research may also explore the actions and conversations between a provider and patient after a provider determines that prescribing an opioid would be risky.In particular, howand when are young people connected with opioid-involvededucation, treatment, and recovery supports.
For policy makers: Prescription drug monitoring programs with mandatory review may confer benefits for youth and young adults. That said, direct causal attribution to the policy, specifically, is unclear from this study as many other simultaneous changes in overdose prevention were happening around the same time. More research is needed to understand the unique contribution of such policy measures. Taken in the context of other similar studieswith older adults, however, it is likely helpful to continue supporting policies that monitor opioid prescriptions for individuals in these life stages. Doing so could have a positive impact on saving lives from opioid overdose and reducing the incidence of opioid use disorder. In addition to surveillance systems like the one in this study, it is equally important to develop policies that promote evidence-based education and connect individuals to substance use treatment and recovery services. Combining these efforts can likely help to address the opioid crisis.
Opioid use, including non-medical prescription drug use, during adolescence and young adulthood can have serious adverse consequences such as the development of a substance use disorder. Rates of drug overdoses among adolescents have also been on the rise. In 2021, there was a 20% increase in overdose deaths compared to 2020, which was nearly double the increased rate of change seen in the overall population. Treatment and recovery services provide help to those currently struggling with opioid use, but policy-level interventions and prevention strategies are also crucial.
Prescription drug monitoring programs are state-level databases that track information on controlled substance prescriptions dispensed by pharmacies to individual patients. Medical providers use the system to identify recently dispensed medications, thereby preventing patients from obtaining opioids and other potentially harmful substances (e.g., benzodiazepines) from multiple providers.
Currently 49 states in the US have implemented such programs. By 2019, 39 states with these programs also mandated that providers review the database prior to prescribing an opioid. Prescription drug monitoring programs may help reduce high-risk opioid prescriptions and minimize the risk of opioid misuse and addiction. However, relatively unexplored is if the rate of opioid prescriptions and related overdoses among adolescents and young adults change in states after they implement such programs. This study examines one commercial insurance claims database containing over 9.3 million young people (aged 13-25) to see if rates of opioid prescriptions and opioid-involved overdoses among adolescents and young adults change after a state implements a prescription drug monitoring program that mandates provider review.
HOW WAS THIS STUDY CONDUCTED?
This study used commercial insurance claims data from over 9.3 million adolescents (aged 13-18) and young adults (aged 19-25) between 2008 and 2019. The number of adolescents and young adults that received an opioid prescription were counted for each month and then summed to give the annual rate of opioid prescriptions. The rate of overdoses among the two groups were derived from the number of adolescents and young adults that had received medical care accompanied by an insurance claim for an opioid-involved overdose (this may result in the underreporting of overdoses). Furthermore, the medical charting and insurance claim data does not distinguish between types of opioids, thus it is unknown whether the opioid overdoses involved fentanyl or fentanyl analogs in this study.
The date when states implemented the prescription drug monitoring program was garnered from the Prescription Drug Monitoring Program Training and Technical Assistance Center. The analysis examined the rates of prescriptions and overdoses in states before and after a state implemented the program, which then enables the study to chart the trends in prescriptions and overdoses among these two populations in the years before and after program implementation. There were additional analyses that measured immediate change in prescriptions and overdoses pre- and post-implementation by restricting analyses to the end of the pre-implementation period to the end of the first month after implementation. The analyses controlled for important state-level policies such as pain clinic legislation and opioid prescribing guidelines outside of the drug monitoring program. However, the analyses did not account for other important state-level policies such as naloxone access laws.
Among the 9.3 million adolescents and young adults in the insurance claims dataset, 1.4 million (15%) had at least one opioid prescription and 6,262 (0.1%) experienced an opioid-involved overdose between 2008 and 2019. Out of the 4.2 million adolescents assessed, 524,445 (12.5 per 100) received an opioid prescription and 1,361 (32.4 per 100,000) experienced an opioid-involved overdose. Among the 6.1 million young adults analyzed, 949,326 (15.4 per 100) received an opioid prescription and 4,941 (80.4 per 100,000) experienced an overdose. Females were prescribed opioids at a higher rate compared to males (16.5 vs. 13.6 per 100), but males experienced overdoses at a higher rate (75 vs. 59 per 100,000). Those living in the South were prescribed opioids at a higher rate compared to the Northeast, Midwest, and West (16 vs. 14, 14, and 15 per 100). Yet those living in the North had the highest rate of overdose compared to those living in the Midwest, South, and West (85 vs. 66, 58, and 63 per 100,000).
WHAT DID THIS STUDY FIND?
Rates of opioid prescriptions decreased more in states with the program.
The rate of opioid prescriptions was found to be on the decline both before and after state implementation of the program. However, states that enacted the program had a larger drop in prescriptions compared to states that did not. Among adolescents, the program was linked to a 4% reduction in opioid prescriptions. For young adults, the program was associated with an 8% reduction in prescriptions. Additionally, there were drops in the rate of prescriptions in the first month immediatelyfollowing implementation of the program among adolescents and young adults—10% and 14% reductions, respectively.
Figure 2. Changes in annual % of dispensed opioid prescriptions after implementation of prescription drug monitoring programs (PDMPs).
Rates of opioid-involved overdoses decreased in states with the program.
Opioid-involved overdoses were increasing among adolescents and young adults before the program was implemented. However, there were reductions in the rates of overdose among both groups in states that enacted the program compared to those that did not. For example, in young adults, an increasing overdose trend before the programs were implemented flattened out after implemented.The study found that the program was associated with 16% reductions in overdoses among adolescents and young adults. Although the program was related to fewer overdoses, there was not an immediate decrease in the rates of overdose among adolescents or young adults following program enactment.
Figure 3. Changes in annual % of opioid-related overdoses after implementation of prescription drug monitoring programs (PDMPs).
Heroin overdoses also decreased in states with the program.
Heroin overdoses were uncommon among adolescents compared to young adults (4 vs. 36 per 100,000). States that implemented the program saw a 17% reduction in heroin-involved overdoses in adolescents and young adults combined.
WHAT ARE THE IMPLICATIONS OF THE STUDY FINDINGS?
This secondary data analysis found states that implemented a prescription drug monitoring program with mandated review had lower rates of opioid prescriptions and opioid-involved overdoses among adolescents and young adults compared to states that did not have the program and before program execution.
Deaths due to drug overdose are steadily increasing among adolescents and young adults in the US. Intervention and prevention strategies vary widely and can include harm-reduction education, opioid reversal (e.g., naloxone) and opioid-use disorder medications (e.g., buprenorphine, methadone), mental health services, substance use treatment, and recovery support services, which may all individually and jointly help reduce opioid-involved harm and overdose.
This study focused on one policy-level prevention strategy and found that there were lower rates of both opioid prescriptions and opioid-involved overdoses among adolescents and young adults in states after they implemented prescription drug monitoring programs with mandated review. Although we cannot say that these programs caused the lower rates in prescriptions or overdoses, they probably helped. That said, these analyses did not control for many policies intended to curb the overdose crisis such as naloxone laws, expanded access to buprenorphine, or syringe services. Furthermore, the benefits of prescription monitoring may take time. In another study, computer modeling suggests the largest public health benefits of reducing opioid prescriptions may not be evident until the second decade of reductions. So, more research is needed to explore how these prescription monitoring programs change prescribing behavior among providers and the downstream impact on adolescents and young adults, especially since only about 20-30% of adolescents and young adults using prescription opioids obtain them from their physician.
Results from this study suggest that prescription monitoring programs may help reduce opioid prescriptions and opioid-involved overdoses. Consequently, policies to monitor and reduce opioid prescriptions should be part of a larger, multi-level national public health strategy that includes expanded access to treatment, harm reduction, and recovery support services, which may have a more immediate impact on reducing opioid-involved harms.
Multi-level strategies are important for many reasons. One reason relevant to this study is that reducing opioid prescriptions may lead to harm for some individuals. Individuals may be adversely affected if their opioid prescription is prematurely or suddenly discontinued without linkage to treatment or compensatory interventions. For example, among adults, there is evidence that reducing access to legal opioids (i.e., prescriptions) leads to increases in illicit opioid use (e.g., heroin). In this study, heroin-involved overdoses did not increase. Youth may not be as physiologically dependent on prescription opioids, on average, so the risks of reducing or eliminating their prescriptions may not be as substantial as for older individuals with longer opioid prescription histories. More research is needed, however, to examine how youth and young adults with opioid-prescription histories respond to reduced opioid prescriptions.
Only one commercial claims database representing 10% of all insured individuals in the US was used for these analyses. So, these results may not generalize to adolescents and young adults on other insurance plans, without insurance, or outside the US.
The analyses were not able to incorporate variables that have been previously linked to substance use and related outcomes such as race, ethnicity, sexual orientation, income, or education.
Opioid-involved overdose was determined by the presence of the ICD-10 diagnosis of opioid poisoning in a medical service claim, which likely underestimates the number of opioid-involved overdoses. Additionally, the ICD-10 opioid-involved overdose diagnosis only indicates either heroin-related overdose orotheropioid-involved overdose. So, the rate of overdoses attributable to fentanyl or fentanyl analogs is unknown.
The data assess the relationship between a state-level policy and annual prescription and overdose rates among individuals. Thus, the study cannot determine if the program caused the rates of prescriptions and overdose to decline among individuals.
BOTTOM LINE
This study analyzed insurance claims among 9.3 million adolescents (aged 13-18) and young adults (aged 19-25) to assess if rates of opioid prescriptions and opioid-involved overdoses changed once statesimplemented a prescription drug monitoring program with mandated review. The study found that prescription rates declined by 4% and 8% among adolescents and young adults, respectively, after program implementation compared to rates prior to program enactment. The study also found that the program was linked to a decline in rates of opioid-involved overdoses by 16% among both adolescents and young adults. Although the study cannot determine if prescription drug monitoring programs caused these declines, they probably helped reduce risky opioid prescriptions and subsequentopioid-involved overdoses. More research is needed to determine how these programs are connected with prescribing practices and overdoses over time. This is especially true since mortality ratesattributed to opioids are on the rise since 2019, the last year captured by the current study data.
For individuals and families seeking recovery: If you or a loved one is going to receive medical care that is typically accompanied by an opioid prescription, it is advised to follow medical recommendations from your provider regarding the medication. Providers in most states are now required to review drug prescription databases to help prevent risky prescribing of medications. The added layers of review surrounding opioid prescriptions have been linked to lower rates of opioid prescriptions and overdose rates among adolescents and young adults aged 13-25.
For treatment professionals and treatment systems: In this secondary analysis of over 9.3 million adolescents and young adults, states saw significant reductions in rates of opioid prescriptions and opioid-involved overdose after they implemented prescription drug monitoring programs with mandated review. The study shows that policy-level prevention strategies like prescription drug monitoring programs may help temper risky opioid prescribing and opioid-involved overdose. However, it is also important to consider empirically supported tapering protocols and linkages to substance use disorder treatment and recovery services for adolescents and young adults.
For scientists:The current study demonstrated a connection between a prescription drug monitoring program and reductions in both the rates of opioid prescriptions and opioid-involved overdoses among adolescents and young adults. Whereas specific causal attributions to the policy are unclear, it is likely to have exerted direct and indirect positive effects. Although the study analyzed a very large sample of young people, future research is needed to confirm if these results apply to those that are not members of this insurer or do not have insurance. Future research may also explore the actions and conversations between a provider and patient after a provider determines that prescribing an opioid would be risky.In particular, howand when are young people connected with opioid-involvededucation, treatment, and recovery supports.
For policy makers: Prescription drug monitoring programs with mandatory review may confer benefits for youth and young adults. That said, direct causal attribution to the policy, specifically, is unclear from this study as many other simultaneous changes in overdose prevention were happening around the same time. More research is needed to understand the unique contribution of such policy measures. Taken in the context of other similar studieswith older adults, however, it is likely helpful to continue supporting policies that monitor opioid prescriptions for individuals in these life stages. Doing so could have a positive impact on saving lives from opioid overdose and reducing the incidence of opioid use disorder. In addition to surveillance systems like the one in this study, it is equally important to develop policies that promote evidence-based education and connect individuals to substance use treatment and recovery services. Combining these efforts can likely help to address the opioid crisis.
Opioid use, including non-medical prescription drug use, during adolescence and young adulthood can have serious adverse consequences such as the development of a substance use disorder. Rates of drug overdoses among adolescents have also been on the rise. In 2021, there was a 20% increase in overdose deaths compared to 2020, which was nearly double the increased rate of change seen in the overall population. Treatment and recovery services provide help to those currently struggling with opioid use, but policy-level interventions and prevention strategies are also crucial.
Prescription drug monitoring programs are state-level databases that track information on controlled substance prescriptions dispensed by pharmacies to individual patients. Medical providers use the system to identify recently dispensed medications, thereby preventing patients from obtaining opioids and other potentially harmful substances (e.g., benzodiazepines) from multiple providers.
Currently 49 states in the US have implemented such programs. By 2019, 39 states with these programs also mandated that providers review the database prior to prescribing an opioid. Prescription drug monitoring programs may help reduce high-risk opioid prescriptions and minimize the risk of opioid misuse and addiction. However, relatively unexplored is if the rate of opioid prescriptions and related overdoses among adolescents and young adults change in states after they implement such programs. This study examines one commercial insurance claims database containing over 9.3 million young people (aged 13-25) to see if rates of opioid prescriptions and opioid-involved overdoses among adolescents and young adults change after a state implements a prescription drug monitoring program that mandates provider review.
HOW WAS THIS STUDY CONDUCTED?
This study used commercial insurance claims data from over 9.3 million adolescents (aged 13-18) and young adults (aged 19-25) between 2008 and 2019. The number of adolescents and young adults that received an opioid prescription were counted for each month and then summed to give the annual rate of opioid prescriptions. The rate of overdoses among the two groups were derived from the number of adolescents and young adults that had received medical care accompanied by an insurance claim for an opioid-involved overdose (this may result in the underreporting of overdoses). Furthermore, the medical charting and insurance claim data does not distinguish between types of opioids, thus it is unknown whether the opioid overdoses involved fentanyl or fentanyl analogs in this study.
The date when states implemented the prescription drug monitoring program was garnered from the Prescription Drug Monitoring Program Training and Technical Assistance Center. The analysis examined the rates of prescriptions and overdoses in states before and after a state implemented the program, which then enables the study to chart the trends in prescriptions and overdoses among these two populations in the years before and after program implementation. There were additional analyses that measured immediate change in prescriptions and overdoses pre- and post-implementation by restricting analyses to the end of the pre-implementation period to the end of the first month after implementation. The analyses controlled for important state-level policies such as pain clinic legislation and opioid prescribing guidelines outside of the drug monitoring program. However, the analyses did not account for other important state-level policies such as naloxone access laws.
Among the 9.3 million adolescents and young adults in the insurance claims dataset, 1.4 million (15%) had at least one opioid prescription and 6,262 (0.1%) experienced an opioid-involved overdose between 2008 and 2019. Out of the 4.2 million adolescents assessed, 524,445 (12.5 per 100) received an opioid prescription and 1,361 (32.4 per 100,000) experienced an opioid-involved overdose. Among the 6.1 million young adults analyzed, 949,326 (15.4 per 100) received an opioid prescription and 4,941 (80.4 per 100,000) experienced an overdose. Females were prescribed opioids at a higher rate compared to males (16.5 vs. 13.6 per 100), but males experienced overdoses at a higher rate (75 vs. 59 per 100,000). Those living in the South were prescribed opioids at a higher rate compared to the Northeast, Midwest, and West (16 vs. 14, 14, and 15 per 100). Yet those living in the North had the highest rate of overdose compared to those living in the Midwest, South, and West (85 vs. 66, 58, and 63 per 100,000).
WHAT DID THIS STUDY FIND?
Rates of opioid prescriptions decreased more in states with the program.
The rate of opioid prescriptions was found to be on the decline both before and after state implementation of the program. However, states that enacted the program had a larger drop in prescriptions compared to states that did not. Among adolescents, the program was linked to a 4% reduction in opioid prescriptions. For young adults, the program was associated with an 8% reduction in prescriptions. Additionally, there were drops in the rate of prescriptions in the first month immediatelyfollowing implementation of the program among adolescents and young adults—10% and 14% reductions, respectively.
Figure 2. Changes in annual % of dispensed opioid prescriptions after implementation of prescription drug monitoring programs (PDMPs).
Rates of opioid-involved overdoses decreased in states with the program.
Opioid-involved overdoses were increasing among adolescents and young adults before the program was implemented. However, there were reductions in the rates of overdose among both groups in states that enacted the program compared to those that did not. For example, in young adults, an increasing overdose trend before the programs were implemented flattened out after implemented.The study found that the program was associated with 16% reductions in overdoses among adolescents and young adults. Although the program was related to fewer overdoses, there was not an immediate decrease in the rates of overdose among adolescents or young adults following program enactment.
Figure 3. Changes in annual % of opioid-related overdoses after implementation of prescription drug monitoring programs (PDMPs).
Heroin overdoses also decreased in states with the program.
Heroin overdoses were uncommon among adolescents compared to young adults (4 vs. 36 per 100,000). States that implemented the program saw a 17% reduction in heroin-involved overdoses in adolescents and young adults combined.
WHAT ARE THE IMPLICATIONS OF THE STUDY FINDINGS?
This secondary data analysis found states that implemented a prescription drug monitoring program with mandated review had lower rates of opioid prescriptions and opioid-involved overdoses among adolescents and young adults compared to states that did not have the program and before program execution.
Deaths due to drug overdose are steadily increasing among adolescents and young adults in the US. Intervention and prevention strategies vary widely and can include harm-reduction education, opioid reversal (e.g., naloxone) and opioid-use disorder medications (e.g., buprenorphine, methadone), mental health services, substance use treatment, and recovery support services, which may all individually and jointly help reduce opioid-involved harm and overdose.
This study focused on one policy-level prevention strategy and found that there were lower rates of both opioid prescriptions and opioid-involved overdoses among adolescents and young adults in states after they implemented prescription drug monitoring programs with mandated review. Although we cannot say that these programs caused the lower rates in prescriptions or overdoses, they probably helped. That said, these analyses did not control for many policies intended to curb the overdose crisis such as naloxone laws, expanded access to buprenorphine, or syringe services. Furthermore, the benefits of prescription monitoring may take time. In another study, computer modeling suggests the largest public health benefits of reducing opioid prescriptions may not be evident until the second decade of reductions. So, more research is needed to explore how these prescription monitoring programs change prescribing behavior among providers and the downstream impact on adolescents and young adults, especially since only about 20-30% of adolescents and young adults using prescription opioids obtain them from their physician.
Results from this study suggest that prescription monitoring programs may help reduce opioid prescriptions and opioid-involved overdoses. Consequently, policies to monitor and reduce opioid prescriptions should be part of a larger, multi-level national public health strategy that includes expanded access to treatment, harm reduction, and recovery support services, which may have a more immediate impact on reducing opioid-involved harms.
Multi-level strategies are important for many reasons. One reason relevant to this study is that reducing opioid prescriptions may lead to harm for some individuals. Individuals may be adversely affected if their opioid prescription is prematurely or suddenly discontinued without linkage to treatment or compensatory interventions. For example, among adults, there is evidence that reducing access to legal opioids (i.e., prescriptions) leads to increases in illicit opioid use (e.g., heroin). In this study, heroin-involved overdoses did not increase. Youth may not be as physiologically dependent on prescription opioids, on average, so the risks of reducing or eliminating their prescriptions may not be as substantial as for older individuals with longer opioid prescription histories. More research is needed, however, to examine how youth and young adults with opioid-prescription histories respond to reduced opioid prescriptions.
Only one commercial claims database representing 10% of all insured individuals in the US was used for these analyses. So, these results may not generalize to adolescents and young adults on other insurance plans, without insurance, or outside the US.
The analyses were not able to incorporate variables that have been previously linked to substance use and related outcomes such as race, ethnicity, sexual orientation, income, or education.
Opioid-involved overdose was determined by the presence of the ICD-10 diagnosis of opioid poisoning in a medical service claim, which likely underestimates the number of opioid-involved overdoses. Additionally, the ICD-10 opioid-involved overdose diagnosis only indicates either heroin-related overdose orotheropioid-involved overdose. So, the rate of overdoses attributable to fentanyl or fentanyl analogs is unknown.
The data assess the relationship between a state-level policy and annual prescription and overdose rates among individuals. Thus, the study cannot determine if the program caused the rates of prescriptions and overdose to decline among individuals.
BOTTOM LINE
This study analyzed insurance claims among 9.3 million adolescents (aged 13-18) and young adults (aged 19-25) to assess if rates of opioid prescriptions and opioid-involved overdoses changed once statesimplemented a prescription drug monitoring program with mandated review. The study found that prescription rates declined by 4% and 8% among adolescents and young adults, respectively, after program implementation compared to rates prior to program enactment. The study also found that the program was linked to a decline in rates of opioid-involved overdoses by 16% among both adolescents and young adults. Although the study cannot determine if prescription drug monitoring programs caused these declines, they probably helped reduce risky opioid prescriptions and subsequentopioid-involved overdoses. More research is needed to determine how these programs are connected with prescribing practices and overdoses over time. This is especially true since mortality ratesattributed to opioids are on the rise since 2019, the last year captured by the current study data.
For individuals and families seeking recovery: If you or a loved one is going to receive medical care that is typically accompanied by an opioid prescription, it is advised to follow medical recommendations from your provider regarding the medication. Providers in most states are now required to review drug prescription databases to help prevent risky prescribing of medications. The added layers of review surrounding opioid prescriptions have been linked to lower rates of opioid prescriptions and overdose rates among adolescents and young adults aged 13-25.
For treatment professionals and treatment systems: In this secondary analysis of over 9.3 million adolescents and young adults, states saw significant reductions in rates of opioid prescriptions and opioid-involved overdose after they implemented prescription drug monitoring programs with mandated review. The study shows that policy-level prevention strategies like prescription drug monitoring programs may help temper risky opioid prescribing and opioid-involved overdose. However, it is also important to consider empirically supported tapering protocols and linkages to substance use disorder treatment and recovery services for adolescents and young adults.
For scientists:The current study demonstrated a connection between a prescription drug monitoring program and reductions in both the rates of opioid prescriptions and opioid-involved overdoses among adolescents and young adults. Whereas specific causal attributions to the policy are unclear, it is likely to have exerted direct and indirect positive effects. Although the study analyzed a very large sample of young people, future research is needed to confirm if these results apply to those that are not members of this insurer or do not have insurance. Future research may also explore the actions and conversations between a provider and patient after a provider determines that prescribing an opioid would be risky.In particular, howand when are young people connected with opioid-involvededucation, treatment, and recovery supports.
For policy makers: Prescription drug monitoring programs with mandatory review may confer benefits for youth and young adults. That said, direct causal attribution to the policy, specifically, is unclear from this study as many other simultaneous changes in overdose prevention were happening around the same time. More research is needed to understand the unique contribution of such policy measures. Taken in the context of other similar studieswith older adults, however, it is likely helpful to continue supporting policies that monitor opioid prescriptions for individuals in these life stages. Doing so could have a positive impact on saving lives from opioid overdose and reducing the incidence of opioid use disorder. In addition to surveillance systems like the one in this study, it is equally important to develop policies that promote evidence-based education and connect individuals to substance use treatment and recovery services. Combining these efforts can likely help to address the opioid crisis.
